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psnet.ahrq.gov/issue/video-analysis-factors-associated-response-time-physiologic-monitor-alarms-childrens-hospital
November 06, 2015 - Study
Video analysis of factors associated with response time to physiologic monitor alarms in a children's hospital.
Citation Text:
Bonafide CP, Localio R, Holmes JH, et al. Video Analysis of Factors Associated With Response Time to Physiologic Monitor Alarms in a Children's Hospital. J…
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psnet.ahrq.gov/issue/understanding-whistleblowing-qualitative-insights-nurse-whistleblowers
April 24, 2018 - Study
Understanding whistleblowing: qualitative insights from nurse whistleblowers.
Citation Text:
Jackson D, Peters K, Andrew S, et al. Understanding whistleblowing: qualitative insights from nurse whistleblowers. J Adv Nurs. 2010;66(10):2194-201. doi:10.1111/j.1365-2648.2010.05365.x.…
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psnet.ahrq.gov/issue/copy-paste-and-cloned-notes-electronic-health-records-prevalence-benefits-risks-and-best
October 19, 2022 - Review
Copy, paste, and cloned notes in electronic health records: prevalence, benefits, risks, and best practice recommendations.
Citation Text:
Weis JM, Levy PC. Copy, paste, and cloned notes in electronic health records: prevalence, benefits, risks, and best practice recommendations. …
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www.ahrq.gov/news/newsroom/case-studies/201512.html
May 01, 2015 - AHRQ’s RED Toolkit Helps VA Hospitals in California and Texas Lower Readmissions, Improve Discharge Process
Search All Impact Case Studies
May 2015
Thirty-day all-cause hospital readmissions at the Department of Veterans Affairs (VA) Palo Alto (CA) Health Care System dropped 30 percent after administrators …
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psnet.ahrq.gov/issue/duty-hours-restriction-and-their-effect-resident-education-and-academic-departments-american
November 16, 2022 - Review
Duty hours restriction and their effect on resident education and academic departments: the American perspective.
Citation Text:
Swide CE, Kirsch JR. Duty hours restriction and their effect on resident education and academic departments: the American perspective. Curr Opin Anaes…
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psnet.ahrq.gov/issue/using-computerized-sign-out-system-improve-physician-nurse-communication
September 28, 2016 - Study
Using a computerized sign-out system to improve physician–nurse communication.
Citation Text:
Sidlow R, Katz-Sidlow RJ. Using a computerized sign-out system to improve physician-nurse communication. Jt Comm J Qual Patient Saf. 2006;32(1):32-36.
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psnet.ahrq.gov/issue/awareness-recall-during-general-anaesthesia-prospective-observational-evaluation-4001
March 09, 2022 - Study
Awareness with recall during general anaesthesia: a prospective observational evaluation of 4001 patients.
Citation Text:
Errando CL, Sigl JC, Robles M, et al. Awareness with recall during general anaesthesia: a prospective observational evaluation of 4001 patients. Br J Anaesth.…
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psnet.ahrq.gov/issue/greatest-impact-safe-harbor-rule-may-be-improve-patient-safety-not-reduce-liability-claims
July 05, 2017 - Study
Greatest impact of safe harbor rule may be to improve patient safety, not reduce liability claims paid by physicians.
Citation Text:
Kachalia A, Little A, Isavoran M, et al. Greatest impact of safe harbor rule may be to improve patient safety, not reduce liability claims paid by p…
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psnet.ahrq.gov/issue/discrepancies-between-prescribed-and-actual-pediatric-home-parenteral-nutrition-solutions
November 11, 2009 - Study
Discrepancies between prescribed and actual pediatric home parenteral nutrition solutions.
Citation Text:
Raphael BP, Murphy M, Gura KM, et al. Discrepancies Between Prescribed and Actual Pediatric Home Parenteral Nutrition Solutions. Nutr Clin Pract. 2016;31(5):654-658. doi:10.117…
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psnet.ahrq.gov/issue/optimising-delivery-remediation-programmes-doctors-realist-review
June 02, 2021 - Review
Optimising the delivery of remediation programmes for doctors: a realist review.
Citation Text:
Price T, Wong G, Withers L, et al. Optimising the delivery of remediation programmes for doctors: a realist review. Med Educ. 2021;55(9):995-1010. doi:10.1111/medu.14528.
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psnet.ahrq.gov/issue/bad-apples-time-redefine-type-systems-problem
April 19, 2017 - Commentary
'Bad apples': time to redefine as a type of systems problem?
Citation Text:
Shojania KG, Dixon-Woods M. 'Bad apples': time to redefine as a type of systems problem? BMJ Qual Saf. 2013;22(7):528-531. doi:10.1136/bmjqs-2013-002138.
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psnet.ahrq.gov/issue/long-term-effects-e-learning-course-patient-safety-controlled-longitudinal-study-medical
March 16, 2016 - Study
Long-term effects of an e-learning course on patient safety: a controlled longitudinal study with medical students.
Citation Text:
Gaupp R, Dinius J, Drazic I, et al. Long-term effects of an e-learning course on patient safety: A controlled longitudinal study with medical students.…
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psnet.ahrq.gov/issue/12-h-shifts-and-rates-error-among-nurses-systematic-review
October 20, 2021 - Review
12 h shifts and rates of error among nurses: a systematic review.
Citation Text:
Clendon J, Gibbons V. 12 h shifts and rates of error among nurses: a systematic review. Int J Nurs Stud. 2015;52(7):1231-1242. doi:10.1016/j.ijnurstu.2015.03.011.
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psnet.ahrq.gov/issue/graduate-medical-educations-new-focus-resident-engagement-quality-and-safety-will-it
July 14, 2021 - Commentary
Graduate medical education's new focus on resident engagement in quality and safety: will it transform the culture of teaching hospitals?
Citation Text:
Myers JS, Nash DB. Graduate Medical Education’s New Focus on Resident Engagement in Quality and Safety. Acad Med. 2014;89(10…
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psnet.ahrq.gov/issue/building-safer-systems-through-critical-occurrence-reviews-nine-years-learning
July 05, 2017 - Study
Building safer systems through critical occurrence reviews: nine years of learning.
Citation Text:
Stevens P, Campbell J, Urmson L, et al. Building safer systems through critical occurrence reviews: nine years of learning. Healthc Q. 2010;13 Spec No:74-80.
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www.ahrq.gov/sites/default/files/publications/files/system-design_0.pdf
July 01, 2011 - Designing Consumer Reporting Systems for Patient Safety Events: Project Overview
Advancing Excellence in Health Care • www.ahrq.gov
Agency for Healthcare Research and Quality PATIENT
SAFETY
Designing Consumer Reporting
Systems for Patient Safety Events
Background
It’s been nearly a decade since the Institute of
M…
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psnet.ahrq.gov/issue/use-high-fidelity-simulation-enhance-interdisciplinary-collaboration-and-reduce-patient-falls
September 23, 2020 - Study
Use of high-fidelity simulation to enhance interdisciplinary collaboration and reduce patient falls.
Citation Text:
Bursiek AA, Hopkins MR, Breitkopf DM, et al. Use of High-Fidelity Simulation to Enhance Interdisciplinary Collaboration and Reduce Patient Falls. J Patient Saf. 2020;…
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psnet.ahrq.gov/issue/association-between-concurrent-use-prescription-opioids-and-benzodiazepines-and-overdose
November 16, 2022 - Study
Association between concurrent use of prescription opioids and benzodiazepines and overdose: retrospective analysis.
Citation Text:
Sun EC, Dixit A, Humphreys K, et al. Association between concurrent use of prescription opioids and benzodiazepines and overdose: retrospective analys…
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psnet.ahrq.gov/issue/do-safety-briefings-improve-patient-safety-acute-hospital-setting-systematic-review
August 14, 2024 - Review
Do safety briefings improve patient safety in the acute hospital setting? A systematic review.
Citation Text:
Ryan S, Ward M, Vaughan D, et al. Do safety briefings improve patient safety in the acute hospital setting? A systematic review. J Adv Nurs. 2019;75(10):2085-2098. doi:10.…
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psnet.ahrq.gov/issue/idea-safety-training-improve-critical-thinking-individuals-and-teams
May 25, 2016 - Commentary
An IDEA: safety training to improve critical thinking by individuals and teams.
Citation Text:
Browne AM, Deutsch ES, Corwin K, et al. An IDEA: Safety Training to Improve Critical Thinking by Individuals and Teams. Am J Med Qual. 2019;34(6):569-576. doi:10.1177/106286061882068…